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Sex Matters

Coitally Related Vulvar Fissures

Susan Kellogg-Spadt, PhD, CRNP

Primarily viewed as a postmenopausal problem, vulvar fissures can also occur as a result of intercourse in women with certain predisposing factors.

The fact that vestibular microfissures, or “paper cuts,” occur commonly at the 6-o’clock region of the introitus is no surprise. This area is poorly keratinized, and is often subjected to maximal friction and pressure during sexual activity. Indeed, the posterior fourchette medial to Hart’s line has only about 1 mm of keratin vertically and 3 mm laterally, promoting inflammation and superficial splitting.1-3 Even so, fissures generally do not occur without some related cause.

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ATROPHIC VULVITIS

One of the most common reasons for increased fragility of the vulvar tissue is atrophic vulvitis. Although this estrogen-deficient state is often associated with postmenopause, other populations at high risk include young women using progestin-only contraception and postpartum/lactating women. The resulting thinning, hypopigmentation, and loss of introital elasticity make the vulvar tissue vulnerable to tearing during vigorous intercourse. Treatment approaches aimed at thickening the tissues and increasing elasticity may include topical introital application of estrogen cream nightly for several weeks. When appropriate, use of an alternative method of contraception should be considered.4

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CANDIDIASIS

Another common cause of genital microfissures is candidal or tinea infection of the dermis. Women at particular risk are those with diabetes, obesity, or immunodeficiency; and those using prolonged antibiotic therapy. The skin in such cases often exhibits dramatic erythema, and the patient may complain of burning and stinging in addition to tearing. These symptoms may or may not be accompanied by an intravaginal discharge. Skin cultures and/or biopsies with fungal staining techniques may be necessary for adequate diagnosis. Fungal-related fissures often occur at the posterior fourchette but may also be located in the interlabial sulci, perianal area, and intergluteal and/or crural folds. Prolonged topical and/or oral antifungal regimens usually improve symptoms after several weeks.4,5

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DERMATITIS

Vulvar fissures are also common in women with chronic atopic dermatitis or neurodermatitis (eg, lichen simplex chronicus, lichen sclerosus). In these women, the lateral margins of the fissure are often white and thickened. These fissures occur because a thickened stratum corneum has reduced elasticity and tends to crack when it is stretched. Vulvar neurodermatitis is thought to be a chronic condition, possibly autoimmune in nature. It may be exacerbated by physical and emotional stress. Diagnosis is verified via vulvoscopically directed skin biopsy. Treatment approaches include topical corticosteroids, oral antihistamines, and lifestyle modification.2-4

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ANATOMIC DEFECTS

An estimated 5% to 10% of women who complain of dyspareunia have anatomic variants, whereby the inferior juncture of the labia minora in the vestibule is both prominent and taut. During penetration and/or thrusting, trauma occurs and the fold of skin at the base of the introitus tears repeatedly. Strategies for management include generous lubrication during intercourse with careful coital positioning, serial subdermal corticosteroid injections into the fissure base, and (in severe cases) modified perineoplasty.3,4

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UNDERLYING DISEASE

It is important to be cautious when managing vulvar fissures because they may be a symptom of a more pervasive and serious disorder (eg, systemic lupus erythematosus, Crohn disease, granuloma inguinale).1,3Therefore, if the patient fails to respond to therapy after several weeks, the diagnosis should be reconsidered.

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PSYCHOLOGICAL IMPLICATIONS

Patients with vulvar fissures often become averse to intimacy. It is important to instruct the patient to abstain from coitus for several weeks while testing and treatment are implemented.6 This will provide her with a vital respite from pain, adequate time for healing, and a chance to re-establish healthy sexual feelings with her partner.

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CONCLUSION

The patient with vulvar fissures presents a number of challenges. Not only is it necessary to discover and treat the underlying cause, but it is also important to help restore the patient’s sexual function and pleasure. Not until both of these needs are met can therapy truly be declared a success.

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Susan Kellogg-Spadt, PhD, CRNP, is assistant professor, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick; and cofounder and director of Vulvar and Sexual Medicine, The Pelvic and Sexual Health Institute, Philadelphia, Penn.

References

1. Wilkinson EJ, Stone IK. Atlas of Vulvar Disease. 5th ed. Baltimore, Md: Williams & Wilkins; 1995:1-9, 77-110.
2. Apgar BS, Brotzman GL, Spitzer M, eds. Colposcopy Principles & Practice: An Integrated Textbook. Philadelphia, Penn: WB Saunders; 2002:343-355.
3. Farage MA. The Vulva: Anatomy, Physiology, and Pathology. Maibach HI, ed. New York, NY: Informa Healthcare; 2006:1-22, 27-39, 63-81.
4. Edwards L, ed. Genital Dermatology Atlas. Philadelphia, Penn: Lippincott Williams & Wilkins; 2004:219-221.
5. Morse SA, Moreland AA, Holmes KK, eds. Atlas of Sexually Transmitted Diseases and AIDS. 3rd ed. London, England: Mosby-Wolfe; 2003:1-22, 169-172.
6. Porst H, Buvat J, eds. Standard Practice in Sexual Medicine. Malden, Mass: Blackwell; 2006:348.

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